Endoscopic Hemoclip Treatment for Gastrointestinal Bleeding K F Binmoeller F by stephan2



                   Endoscopic Hemoclip Treatment
                   for Gastrointestinal Bleeding

                   K. F. Binmoeller, F. Thonke, N. Soehendra
                   Department of Endoscopic Surgery, University Hospital Eppendorf Hamburg, Germany

We conducted an uncontrolled study to evaluate an improved
metallic clip (Olympus hemoclip) for the endoscopic treatment of
nonvariceal gastrointestinal bleeding. A total of 88 patients (mean
age 63±14, 60 males) with bleeding from a wide range of sources
were treated. Seventy-eight patients had active bleeding (spurting
in 50, oozing in 28) and 10 patients had a nonbleeding visible
vessel. Initial hemostasis was achieved in all patients with active
bleeding. A total of 255 clips were placed (average of 2.9 clips per
patient, range of 1-10 clips). Spurting arterial bleeders required
more clips on average than oozing bleeders (3.2 versus 2.7); active
bleeders required more clips than cases with nonbleeding visible
vessels (3.0 versus 2.2). Mean follow-up was 397±148 days.                  Figure 1: Hemoclip application device consisting of handle and
Recurrent bleeding was observed in 5 patients, all of whom had              sheath with an inner cable. Insert shows attachment of a hemoclip to
                                                                            the tip of the cable.
active bleeding on initial presentation. Rebleeding was successfully
treated with hemoclips in 4 patients and one patient underwent
surgery. Clips appeared to be retained well; early clip                     Conceptually, mechanical hemostasis by the application of a metal
dislodgement resulted in rebleeding in only 1 patient. No                   hemoclip to a bleeding vessel is an appealing alternativ e to the
complications resulted from this treatment. Clips did not impair            currently available techniques. The bleeding ves sel is ligated, thus
healing of peptic ulcers. We conclude that endoscopic hemoclip              achieving an immediate hemostatic effect analogous to surgical
placement is a highly effective and safe method for treating                ligation. Hemostasis is definitive if the vessel is properly ligated. Injury
nonvariceal gastrointestinal bleeding and de serves comparative             to the surrounding tissue is minimized owing to the targeted
studies with other methods of endoscopic hemostasis.                        application of the clip to the bleeding vessel.

                                                                            A method for endoscopic hemostasis using a metallic clip was
                                                                            introduced by Hayashi nearly two decades ago in Japan (14). Initial
                                                                            experience was discouraging owing to the complicated technique of
                                                                            clip application and low retention rates. More recently, technical
                                                                            improvements of both the clip and clip delivery system have been
Introduction                                                                introduced. The modified clips have been reported to be easier to place,
                                                                            to have a better grasping capability and to cause less tissue trauma
Widely practiced endoscopic methods for nonvariceal hemostasis              (14,15). Hachisu reported permanent hemostasis of upper
include thermal application (laser, heater probe, and Bicap) and local      gastrointestinal bleeding in 84.3 % of 51 patients treated with modified
injection (epinephrine or various sclerosing agents) . Studies evaluating   hemoclips (15). We performed a prospective study to evaluate this
these modalities for upper gastrointestinal bleeding (primarily peptic      improved metallic clip for hemostasis of gastrointestinal bleeding from
ulcers) have presented high success rates for achieving initial he-         a wide variety of sources.
mostasis (1). However, rebleeding has been reported to occur in 10-30
% of patients (2-7). A potential drawback of thermal methods and the
injection of sclerosing agents is that these may cause excessive tissue
injury leading to necrosis and perforation (8-13).

                                                                            Over a two year period (1990-1992), a total of 88 patients with
                                                                            nonvariceal gastrointestinal bleeding were included in this study. There
Endoscopy 1993; 25: 167-170                                                 were 60 males and 28 females with a mean age of 63±14 years. All of
  Georg Thieme Verlag Stuttgart - New York                                  the patients we selected had
168Endoscopy 1993; 25                                                                                                       K. F. Binmoeller F. Thonke, N. Soehend~

      Figure 2a: Open hemoclip (open arrows)                        Figure 2b: Hemostasis after application of the            Figure 2c: Hemoclip in situ after detachment.
      approaching a spurting artery (curved solid arrow).           hemoclip.

      Figure 2: Endoscopic views of hemoclip application for a bleeding gastric ulcer.

      either active bleeding (spurting or oozing) on endoscopy or clinical                         of which 64 % had a spurting bleed. Sources of bleeding and bleeding
      documentation of hematemesis, hematochezia, or melena and a nonbleeding                      activity are detailed in Table 1.
      visible on endoscopy. Upper and lower endoscopy were performed on an
      emergency basis within 24 hours of hospital presentation for gastrointestinal                Endoscopy was performed in the standard fashion using the Olympus
      bleeding. We excluded patients with bleeding from a large caliber (> 2 mm)                   GIF-IT20 (3.7 mm working channel) and CFIT20I (4.2 mm working
      artery and ulcers suspected of perforation. None of the patients had                         channel) endoscopes. Hemoclips (MD 850, Olympus Corp., Toyko) were
      undergone prior endoscopic treatment of any kind. Most patients (89 %) had                   made of stainless steel and had prongs which measured 6 mm in length and
      active bleeding,                                                                             1.2 mm in width. When fully open, the distance between the clip prongs
                                                                                                   measured 7 mm. Clips were applied with a clip application device (HX-3L,
                                                                                                   Olympus Corp., Tokyo) which can also be passed through a 2.8 working
                                                                                                   channel of a standard endoscope (Figure 1).
      Table 1: Sources of gastrointestinal bleeding and bleed -
      ing activity (n=88).
                                              Spurting          Oozing      Visible Vessel
      I. Upper GI tract
      Peptic ulcer
      Gastric                                         6              3            5                Hemoclips were applied directly to the bleeding vessel (Figures 2,3). Vessels
      Duodenal                                        4
      Esophageal                                      2              1                             traversing the surface were clipped at both ends of the bleeding point (Figure
      Stomal ulcer                                    2              1            3                4). The orientation of the opened clip was adjusted by rotating the applicator
      Mallory-Weiss tear                              2
      Dieulafoy's lesion                              1                                            handle.
      Gastric tumor                                                  1            1                Patients with upper gastrointestinal ulcers received acid suppressive therapy
      Gastric AVM                                     1
      II. Lower GI tract                                                                           and underwent follow-up endoscopy on a weekly basis. A clear ulcer base
      Colonic diverticulum                            1                                            (including dislodgement of the clip) was ascertained before hospital
      Solitary rectal ulcer                           1                           1
      Hemorrhoids                                     1                                            discharge. Emergency endoscopy was performed if there was clinical
      III. Postprocedural                                                                          suspicion of rebleeding. All other patients did not undergo followup
      Colon                                          24             18                             endoscopy unless clinically suspected of having recurrent bleeding.
      Stomach                                         3              4
      Postsphincterotomy                              1
      Postbiopsy (tumor at                            1
      gastric anastomosis)
      Total                                          50             28            10
      GI = Gastrointestinal, AVM = Arteriovenous malformation


                                                                                                   A total of 255 clips were placed (average of 2.9 clips per patient). Sixteen
                                                                                                   patients received a single clip, 55 patients two to three clips and 17 patients
                                                                                                   four or more clips. The maximum number of clips applied was ten (one
                                                                                                   patient). Initial hemostasis was secured in all patients with active
Endoscopic Hemoclip Treatment                                                                                                                     Endoscopy 1993; 25169
                                                                                                                                                     Figure 3b: Hemostasis
                                                                                                                                                     after application of 1
                                                              Figure 3a: Spurting arterial                                                           hemoclip (arrow) to the
                                                              bleed (arrow) after snare                                                              bleeding vessel at the
                                                              excision of a 2 cm                                                                     polyp stalk.
                                                              pedunculated polyp

Figure 3: Endoscopic views of hemoclip application for a postpolypectomy bleed.

                                                                                             Follow-up endoscopy of patients with bleeding upper gastrointestinal ulcers
                                                                                             showed no evidence of clip -induced tissue injury or impairment of ulcer
                                                                                             healing. Clips were observed to dislodge spontaneously with reepithelization
                                                                                             of the ulcer base. This occurred 1-3 weeks after placement. The clips were
                                                                                             passed in the feces without any complication.


Figure4: Graphic representation of hemoclip application to a bleeding vessel. A:             The results of this study confirm the efficacy and safety of hemoclips for the
Protruding vessel. B: Clips applied at both ends of a bleeding vessel.
                                                                                             treatment of gastrointestinal bleeding as reported previously by Hachisu
                                                                                             (15). Hemoclip placement was technically successful in all patients treated.
                                                                                             Initial hemostasis was achieved in 100 % of the cases and the rebleeding rate
bleeding. Patients with a spurting arterial bleed required more clips to                     was low (5 %). No complications resulted from clip placement. Based on
achieve hemostasis on average than those with an oozing bleed (3.2 versus                    follow-up endoscopy in patients with peptic ulcer bleeding, the clips were
2.7). Active bleeding required more clips on average than n        onbleeding                well retained. Early dislodgement of a clip resulting in rebleeding was
visible vessels (3.0 versus 2.2). In the first seven patients we encountered                 observed in only one case. Clips did not appear to impair healing of ulcers.
with active bleeding, epinephrine (1 : 20,000) was injected around the                       The number of hemoclips required for hemostasis depended upon the
bleeding site as a preliminary step to reduce bleeding. In subsequent                        bleeding activity, endoscopic accessibility of the bleeding site and anatomy
patients, hemostasis was achieved with hemoclips alone. Hemoclip                             of the vessel. Spurting lesions generally required a larger number of clips to
placement did not precipitate active bleeding in any of the patients treated                 achieve hemostasis than oozing lesions, and active bleeding required more
for a nonbleeding visible vessel.                                                            clips than nonbleeding visible vessels. It was usually technically more
The mean follow-up was 397 ± 148 days. Recurrent bleeding occurred in                        difficult to clip a vessel when the angle of approach was tangential. When
five patients. Sources of rebleeding were peptic ulcers in three patients, an                the vessel traversed the surface, it was necessary to place at least two clips to
esophageal ulcer in one patient and a postpolypectomy bleed in one patient.                  ligate the vessel proximally and distally to the bleeding point.
All of these patients had had active bleeding at the time of initial                         In the initial phase of this study, we injected epinephrine around the
presentation. Recurrent bleeding occurred 1-8 days after hemoclip treatment.                 bleeding site in seven patients to reduce bleeding prior to clip placement.
In one patient with a gastric ulcer, the cause of rebleeding was dislodgement                Subsequently, this was not found to be necessary and hemoclips were
of the original clip placed two days earlier. In the remaining four patients,                applied directly to the bleeding point, grasping a maximal amount of
oozing was noted alongside the previously applied clips. Recurrent bleeding                  submucosal tissue between the clip prongs. In some cases, this necessitated
was treated by hemoclips in four patients and resulted in permanent                          the placement of many clips (18 patients required 4 or more clips; 10 clips
hemostasis; one patient had massive bleeding and was referred for                            were applied in one patient).
emergency surgery. None of the patients with nonbleeding visible vessels
had recurrent bleeding.
170Endoscopy 1993; 25                                                                                            K. F. Binmoeller F. Thonke, N. Soehendra

       We encountered several technical difficulties with the hemoclip delivery         References
       system. Loading of the clip onto the application device was cumbersome and
       time consuming - a particular drawback in the setting of active bleeding. We      1. Cook DJ, Guyatt GH, Salena BJ, Laine L:        Endoscopic therapy for a   cute
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                                                                                            Corresponding Author
                                                                                           K. F. Binmoeller, M.D. Department of Endoscopic Surgery
                                                                                           Martinistrasse 52, 2000 Hamburg 20, Germany
                                                                                           Submitted: 9 June 1992 Accepted after revision:
                                                                                           24 November 1992

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